MEDICARE: TRI-STAR HOME CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency	100034442	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780103531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI-STAR HOME CARE, LLC

Provider Business Mailing Address
First Line	:	4250 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3564
Country	:	US
Telephone Number	:	414-897-0050
Fax Number	:	414-897-0052

Provider Business Practice Location Address
First Line	:	4250 W FOND DU LAC AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-3564
Country	:	US
Telephone Number	:	414-897-0050
Fax Number	:	414-897-0052

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. KOUA F THAO
Credential	:
Telephone Number	:	414-897-0050

Provider Enumeration Date	:	09/13/2017
Last Update Date	:	07/21/2022

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